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2020 MEDICARE LOCAL COVERAGE ARTICLE (LCA) - A55001 PROCEDURE CODES: G0480, G0481, G0482, G0483, G0659, 80305, 80306, 80307 Billing and Coding: Controlled Substance Monitoring and of Abuse Testing For services performed on or after 6-28-2016

DLS TEST CODE AND NAME 1203 SALICYLATES 2236 IMIPRAMINE & DESIPRAMINE 2857 TOX - SAP 7AB 3557 TOX - SAP 5A 39176 CLORAZEPATE 4008 NORTRIPTYLINE 40087 GC/MS NIDA LAB 41787 TOX - SAP 6BO 41797 TOX - SAP 7 ABO 41849 DIAZEPAM AND METABOLITE 41919 SCREEN, URINE 41929 ANTIDEPRESSANTS CONFIRMATION, URINE 41970 NICOTINE AND METABOLITES 43327 SUBSTANCE IDENTIFICATION 43357 ETHANOL 45517 NIDA 5, GC/MS 46047 AMPHETAMINE D,L SEP NIDA 46057 ETHANOL, CLINICAL URINE 46827 TOX - SAP 6 NG 47163 MECONIUM (MEC STAT-5) 47267 TOX - SAP 9A, GC/MS 47277 TOX - SAP 11A, GC/MS 47287 TOX - SAP 5, GC/MS 47297 TOX - SAP 10 47307 TOX - SAP 11A 47317 CLINICAL SUBSTANCE ABUSE PANEL 5 47327 CLINICAL SUBSTANCE ABUSE PANEL 7 47337 CLINICAL SUBSTANCE ABUSE PANEL 9A 47347 CLINICAL SUBSTANCE ABUSE PANEL 10 47357 CLINICAL SUBSTANCE ABUSE PANEL 10A 47367 CLINICAL SUBSTANCE ABUSE PANEL 11A 47377 TOX - SAP 10, GC/MS 47387 TOX - SAP 5A,GC/MS 47397 TOX - SAP 6, GC/MS 47407 TOX - SAP 7, GC/MS 47417 TOX - SAP 7A, GC/MS 47427 TOX - SAP 4, GC/MS 47846 COMPREHENSIVE URINE SCREEN 49150 / AMPHETAMINE URINE SCRN 49177 6-MONOACETYLMORPHINE

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 1 of 13 49237 AMPHETAMINES, CLINICAL UR 49247 BARBITURATES, CLINICAL URINE 49257 BENZODIAZEPINES, CLINICAL URINE 49267 COCAINE METABOLITE 49277 METHADONE, CLINICAL URINE 49287 OPIATES, CLINICAL UR 49297 PHENCYCLIDINE, CLINICAL UR 49307 PROPOXYPHENE, CLINICAL UR 49317 THC, CLINICAL UR 49347 PROPOXYPHENE, URINE CONFIRMATION 49569 FELBAMATE 49689 IBUPROFEN 49729 HYPOGLYCEMIC PANEL 49739 TEMAZEPAM (RESTORIL) 504716 DRUGS OF ABUSE SCREEN (7 PANEL), MECONIUM 50439 HYDROCODONE AND METABOLITES 50449 OXYCODONE & METABOLITE 50459 ALPRAZOLAM AND METABOLITE 508100 URINE DRUG SCREEN, #2 (MEDICAL) 51419 NICOTINE AND COTININE - URINE 51717 TOX - SAP 5 LP, GC/MS 52699 ETHYL GLUCURONIDE, RANDOM URINE 54697 TOX - SAP 5, GC/MS POC 54767 TOX - SAP 5, POC 54847 TOX - SAP 4 W/O THC, GC/MS 55437 TOX - SAP 6 X 55447 TOX - SAP 11 X 55757 CLINICAL SUBSTANCE ABUSE PANEL 11 E 56140 MDMA, URINE CONFIRMATION 56747 TOX - SAP 5, GC/MS-DISC 58279 DRUGS OF ABUSE 2 (AMPHETAMINES) 58289 DRUGS OF ABUSE 3 (BARBITURATES) 58299 DRUGS OF ABUSE 4 (BENZODIAZEPINES) 58319 DRUGS OF ABUSE 5 (COCAINE & METABOLITE) 58329 DRUGS OF ABUSE 6 (OPIATES) 58339 DRUGS OF ABUSE 7 (OXYCODONE) 58359 DRUGS OF ABUSE 9 (THC METABOLITES) 58369 DRUGS OF ABUSE 10 (METHADONE) 58379 DRUGS OF ABUSE 11 (PROPOXYPHENE) 58687 CLINICAL SUBSTANCE ABUSE PANEL 8 OX 58907 6-ACETYLMORPHINE, UR. SCRN, CLINICAL 58917 6-ACETYLMORPHINE UR. SCRN FORENSIC 58927 HYDROCODONE, UR. SCRN, CLINICAL 58937 BUPRENORPHINE, URINE SCREEN 59847 TOX - SAP 6AB, INTAKE 59857 EXPANDED OPIATES 60119 PHOSPHATIDYLETHANOL (PETH) 61917 TOX - SAP 9, GC/MS 63708 ETHYL GLUCURONIDE, RANDOM URINE 64237 OXYCODONE, CLINICAL URINE 64247 TOX - CLINICAL SAP 6 OA 64257 TOX - CLINICAL SAP 8 OA 64267 TOX - CLINICAL SAP 10 OA 64277 TOX - CLINICAL SAP 11 OA 66387 TOX - SAP 5 D, GC/MS

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 2 of 13 66430 EXPANDED OPIATES, GC/MS URINE 67347 TOX - CLINICAL SAP 10 XO 67377 MDMA (ECSTACY), URINE SCREEN 6988 DESIPRAMINE 7013 ACETAMINOPHEN (TYLENOL) 7026 AMITRIPTYLINE & NORTRIPTYLINE 71190 NICOTINE AND COTININE 71200 COMPREHENSIVE DRUG SCREEN, SERUM 71887 SAP 4 GC/MS, REF 71897 SAP 10 GC/MS, REF 71949 SYNTHETIC CANNABINOID METAB., URINE 72207 ETHYL GLUCURONIDE, URINE SCREEN 72217 TOX - SAP 7A, INTAKE 72257 ETHYL GLUCURONIDE, URINE CONFIRMATION 7257 CLINICAL SUBSTANCE ABUSE PANEL 8A 7577 AMPHETAMINE/METH, URINE CONFIRMATION 76207 SYNTHETIC CANNABINOIDS SCREEN, 76217 NPS SCREEN 1, BLOOD 76227 NPS SCREEN 2, BLOOD 76257 NOVEL PSYCHOACTIVE SUB. SCREEN, URINE 7677 BENZODIAZEPINES, URINE CONFIRMATION 7727 , CHIRAL CONFIRM 7847 METHAQUALONE, URINE CONFIRMATION 7877 COCAINE, URINE CONFIRMATION 7927 OPIATES, CONFIRM - URINE 7998 CLONAZEPAM 8007 THC, CONFIRM, URINE 8095 TOX - SAP 7 8107 URINE DRUG SCREEN, #2 (MEDICAL) 8108 URINE DRUG SCREEN, #2 (MEDICAL) 8113 DRUG SCREEN # 4 (MEDICAL) 8115 TOX - SAP 4 8118 DRUG SCREEN # 4 (MEDICAL) 8199 TRAZODONE 8207 URINE DRUG SCREEN, #2 (MEDICAL) 8227 BUPRENORPHINE CONFIRMATION, URINE 8347 METHAQUALONE, URINE FORENSIC SCREEN 8737 METHADONE, URINE CONFIRMATION 8747 BARBITURATES, URINE CONFIRMATION 8767 METHADONE, URINE FORENSIC SCREEN 8777 BENZODIAZEPINES, URINE FORENSIC SCREEN 8797 ETHANOL, URINE FORENSIC SCREEN 8855 CLINICAL SUBSTANCE ABUSE PANEL 5A

ICD-10 CODE DESCRIPTION E87.2 Acidosis F10.11 Alcohol abuse, in remission F10.130 Alcohol abuse with withdrawal, uncomplicated F10.131 Alcohol abuse with withdrawal delirium F10.132 Alcohol abuse with withdrawal with perceptual disturbance F10.20 Alcohol dependence, uncomplicated F11.11 Opioid abuse, in remission F11.13 Opioid abuse with withdrawal F11.20 Opioid dependence, uncomplicated

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 3 of 13 ICD-10 CODE DESCRIPTION F11.220 Opioid dependence with intoxication, uncomplicated F11.221 Opioid dependence with intoxication delirium F11.222 Opioid dependence with intoxication with perceptual disturbance F11.229 Opioid dependence with intoxication, unspecified F11.23 Opioid dependence with withdrawal F11.24 Opioid dependence with opioid-induced mood disorder F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified F11.281 Opioid dependence with opioid-induced sexual dysfunction F11.282 Opioid dependence with opioid-induced sleep disorder F11.288 Opioid dependence with other opioid-induced disorder F11.29 Opioid dependence with unspecified opioid-induced disorder F12.11 Cannabis abuse, in remission F12.13 Cannabis abuse with withdrawal F12.23 Cannabis dependence with withdrawal F12.93 Cannabis use, unspecified with withdrawal F13.11 , or abuse, in remission F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance F14.11 Cocaine abuse, in remission F14.13 Cocaine abuse, unspecified with withdrawal F14.93 Cocaine use, unspecified with withdrawal F15.11 Other abuse, in remission F15.13 Other stimulant abuse with withdrawal F16.11 abuse, in remission F18.10 Inhalant abuse, uncomplicated F18.11 Inhalant abuse, in remission F18.120 Inhalant abuse with intoxication, uncomplicated F18.90 Inhalant use, unspecified, uncomplicated F19.11 Other psychoactive substance abuse, in remission F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated F19.131 Other psychoactive substance abuse with withdrawal delirium F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance F19.20 Other psychoactive substance dependence, uncomplicated F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.89 Other schizophrenia F55.0 Abuse of F55.1 Abuse of herbal or folk remedies F55.2 Abuse of F55.3 Abuse of steroids or hormones F55.4 Abuse of F55.8 Abuse of other non-psychoactive substances Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status G40.301 epilepticus Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status G40.309 epilepticus

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 4 of 13 ICD-10 CODE DESCRIPTION G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status G40.319 epilepticus G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus Other generalized epilepsy and epileptic syndromes, not intractable, without status G40.409 epilepticus G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus

G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder G40.901 Epilepsy, unspecified, not intractable, with status epilepticus G40.909 Epilepsy, unspecified, not intractable, without status epilepticus G40.911 Epilepsy, unspecified, intractable, with status epilepticus G40.919 Epilepsy, unspecified, intractable, without status epilepticus G89.29 Other chronic pain G89.4 Chronic pain syndrome I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree I44.30 Unspecified atrioventricular block I45.81 Long QT syndrome I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I49.2 Junctional premature depolarization M25.50 Pain in unspecified M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.59 Pain in other specified joint M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region M47.22 Other spondylosis with radiculopathy, cervical region M47.23 Other spondylosis with radiculopathy, cervicothoracic region M47.26 Other spondylosis with radiculopathy, lumbar region M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region M47.812 Spondylosis without myelopathy or radiculopathy, cervical region M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region M47.891 Other spondylosis, occipito-atlanto-axial region M47.892 Other spondylosis, cervical region M47.893 Other spondylosis, cervicothoracic region M47.896 Other spondylosis, lumbar region M47.897 Other spondylosis, lumbosacral region M47.898 Other spondylosis, sacral and sacrococcygeal region M51.14 Intervertebral disc disorders with radiculopathy, thoracic region

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 5 of 13 ICD-10 CODE DESCRIPTION M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region M51.16 Intervertebral disc disorders with radiculopathy, lumbar region M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M51.36 Other intervertebral disc degeneration, lumbar region M51.37 Other intervertebral disc degeneration, lumbosacral region M54.10 Radiculopathy, site unspecified M54.12 Radiculopathy, cervical region M54.14 Radiculopathy, thoracic region M54.15 Radiculopathy, thoracolumbar region M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M54.18 Radiculopathy, sacral and sacrococcygeal region M54.2 Cervicalgia M54.5 Low back pain M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M79.2 Neuralgia and neuritis, unspecified M79.7 Fibromyalgia R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission R40.2120 Coma scale, eyes open, to pain, unspecified time R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 6 of 13 ICD-10 CODE DESCRIPTION R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] Coma scale, best verbal response, incomprehensible words, at arrival to emergency R40.2222 department R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital R40.2224 admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival to emergency department R40.2313 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]

R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital R40.2344 admission R41.82 Altered mental status, unspecified R44.0 Auditory hallucinations R44.2 Other hallucinations R44.3 Hallucinations, unspecified R45.850 Homicidal ideations R45.851 Suicidal ideations R56.9 Unspecified convulsions T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter T39.012A Poisoning by aspirin, intentional self-harm, initial encounter T39.013A Poisoning by aspirin, assault, initial encounter T39.014A Poisoning by aspirin, undetermined, initial encounter T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter T39.092A Poisoning by salicylates, intentional self-harm, initial encounter T39.093A Poisoning by salicylates, assault, initial encounter T39.094A Poisoning by salicylates, undetermined, initial encounter T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial encounter T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 7 of 13 ICD-10 CODE DESCRIPTION T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter T39.311A Poisoning by propionic acid derivatives, accidental (unintentional), initial encounter T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter T39.313A Poisoning by propionic acid derivatives, assault, initial encounter T39.314A Poisoning by propionic acid derivatives, undetermined, initial encounter Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), T39.391A initial encounter Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial T39.392A encounter T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial T39.394A encounter T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter T40.0X2A Poisoning by opium, intentional self-harm, initial encounter T40.0X3A Poisoning by opium, assault, initial encounter T40.0X4A Poisoning by opium, undetermined, initial encounter T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter T40.1X3A Poisoning by heroin, assault, initial encounter T40.1X4A Poisoning by heroin, undetermined, initial encounter T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter T40.2X3A Poisoning by other opioids, assault, initial encounter T40.2X4A Poisoning by other opioids, undetermined, initial encounter T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter T40.3X3A Poisoning by methadone, assault, initial encounter T40.3X4A Poisoning by methadone, undetermined, initial encounter T40.411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter

T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter T40.411S Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), sequela T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter T40.412S Poisoning by fentanyl or fentanyl analogs, intentional self-harm, sequela T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter T40.413S Poisoning by fentanyl or fentanyl analogs, assault, sequela T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter T40.414S Poisoning by fentanyl or fentanyl analogs, undetermined, sequela T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter T40.421S Poisoning by tramadol, accidental (unintentional), sequela T40.422A Poisoning by tramadol, intentional self-harm, initial encounter T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter T40.422S Poisoning by tramadol, intentional self-harm, sequela

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 8 of 13 ICD-10 CODE DESCRIPTION T40.423A Poisoning by tramadol, assault, initial encounter T40.423D Poisoning by tramadol, assault, subsequent encounter T40.423S Poisoning by tramadol, assault, sequela T40.424A Poisoning by tramadol, undetermined, initial encounter T40.424D Poisoning by tramadol, undetermined, subsequent encounter T40.424S Poisoning by tramadol, undetermined, sequela T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter T40.491S Poisoning by other synthetic narcotics, accidental (unintentional), sequela T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter T40.492S Poisoning by other synthetic narcotics, intentional self-harm, sequela T40.493A Poisoning by other synthetic narcotics, assault, initial encounter T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter T40.493S Poisoning by other synthetic narcotics, assault, sequela T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter T40.494S Poisoning by other synthetic narcotics, undetermined, sequela T40.601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter T40.602A Poisoning by unspecified narcotics, intentional self-harm, initial encounter T40.603A Poisoning by unspecified narcotics, assault, initial encounter T40.604A Poisoning by unspecified narcotics, undetermined, initial encounter T40.691A Poisoning by other narcotics, accidental (unintentional), initial encounter T40.692A Poisoning by other narcotics, intentional self-harm, initial encounter T40.693A Poisoning by other narcotics, assault, initial encounter T40.694A Poisoning by other narcotics, undetermined, initial encounter T40.7X1A Poisoning by cannabis (derivatives), accidental (unintentional), initial encounter T40.7X2A Poisoning by cannabis (derivatives), intentional self-harm, initial encounter T40.7X3A Poisoning by cannabis (derivatives), assault, initial encounter T40.7X4A Poisoning by cannabis (derivatives), undetermined, initial encounter T40.8X1A Poisoning by lysergide [LSD], accidental (unintentional), initial encounter T40.8X2A Poisoning by lysergide [LSD], intentional self-harm, initial encounter T40.8X3A Poisoning by lysergide [LSD], assault, initial encounter T40.8X4A Poisoning by lysergide [LSD], undetermined, initial encounter Poisoning by unspecified psychodysleptics [], accidental (unintentional), initial T40.901A encounter Poisoning by unspecified psychodysleptics [hallucinogens], intentional self-harm, initial T40.902A encounter T40.903A Poisoning by unspecified psychodysleptics [hallucinogens], assault, initial encounter

T40.904A Poisoning by unspecified psychodysleptics [hallucinogens], undetermined, initial encounter Poisoning by other psychodysleptics [hallucinogens], accidental (unintentional), initial T40.991A encounter T40.992A Poisoning by other psychodysleptics [hallucinogens], intentional self-harm, initial encounter T40.993A Poisoning by other psychodysleptics [hallucinogens], assault, initial encounter T40.994A Poisoning by other psychodysleptics [hallucinogens], undetermined, initial encounter T42.0X1A Poisoning by hydantoin derivatives, accidental (unintentional), initial encounter T42.0X2A Poisoning by hydantoin derivatives, intentional self-harm, initial encounter

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 9 of 13 ICD-10 CODE DESCRIPTION T42.0X3A Poisoning by hydantoin derivatives, assault, initial encounter T42.0X4A Poisoning by hydantoin derivatives, undetermined, initial encounter T42.3X1A Poisoning by barbiturates, accidental (unintentional), initial encounter T42.3X2A Poisoning by barbiturates, intentional self-harm, initial encounter T42.3X3A Poisoning by barbiturates, assault, initial encounter T42.3X4A Poisoning by barbiturates, undetermined, initial encounter T42.4X1A Poisoning by benzodiazepines, accidental (unintentional), initial encounter T42.4X2A Poisoning by benzodiazepines, intentional self-harm, initial encounter T42.4X3A Poisoning by benzodiazepines, assault, initial encounter T42.4X4A Poisoning by benzodiazepines, undetermined, initial encounter Poisoning by other antiepileptic and sedative-hypnotic drugs, accidental (unintentional), initial T42.6X1A encounter Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial T42.6X2A encounter T42.6X3A Poisoning by other antiepileptic and sedative-hypnotic drugs, assault, initial encounter

T42.6X4A Poisoning by other antiepileptic and sedative-hypnotic drugs, undetermined, initial encounter Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, accidental T42.71XA (unintentional), initial encounter Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, intentional self-harm, T42.72XA initial encounter T42.73XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, assault, initial encounter Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, undetermined, initial T42.74XA encounter T43.011A Poisoning by tricyclic antidepressants, accidental (unintentional), initial encounter T43.012A Poisoning by tricyclic antidepressants, intentional self-harm, initial encounter T43.013A Poisoning by tricyclic antidepressants, assault, initial encounter T43.014A Poisoning by tricyclic antidepressants, undetermined, initial encounter T43.021A Poisoning by tetracyclic antidepressants, accidental (unintentional), initial encounter T43.022A Poisoning by tetracyclic antidepressants, intentional self-harm, initial encounter T43.023A Poisoning by tetracyclic antidepressants, assault, initial encounter T43.024A Poisoning by tetracyclic antidepressants, undetermined, initial encounter Poisoning by monoamine-oxidase-inhibitor antidepressants, accidental (unintentional), initial T43.1X1A encounter Poisoning by monoamine-oxidase-inhibitor antidepressants, intentional self-harm, initial T43.1X2A encounter T43.1X3A Poisoning by monoamine-oxidase-inhibitor antidepressants, assault, initial encounter

T43.1X4A Poisoning by monoamine-oxidase-inhibitor antidepressants, undetermined, initial encounter

T43.201A Poisoning by unspecified antidepressants, accidental (unintentional), initial encounter T43.202A Poisoning by unspecified antidepressants, intentional self-harm, initial encounter T43.203A Poisoning by unspecified antidepressants, assault, initial encounter T43.204A Poisoning by unspecified antidepressants, undetermined, initial encounter Poisoning by selective serotonin and norepinephrine reuptake inhibitors, accidental T43.211A (unintentional), initial encounter

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 10 of 13 ICD-10 CODE DESCRIPTION Poisoning by selective serotonin and norepinephrine reuptake inhibitors, intentional self- T43.212A harm, initial encounter Poisoning by selective serotonin and norepinephrine reuptake inhibitors, assault, initial T43.213A encounter Poisoning by selective serotonin and norepinephrine reuptake inhibitors, undetermined, initial T43.214A encounter Poisoning by selective serotonin reuptake inhibitors, accidental (unintentional), initial T43.221A encounter T43.222A Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter T43.223A Poisoning by selective serotonin reuptake inhibitors, assault, initial encounter T43.224A Poisoning by selective serotonin reuptake inhibitors, undetermined, initial encounter T43.291A Poisoning by other antidepressants, accidental (unintentional), initial encounter T43.292A Poisoning by other antidepressants, intentional self-harm, initial encounter T43.293A Poisoning by other antidepressants, assault, initial encounter T43.294A Poisoning by other antidepressants, undetermined, initial encounter Poisoning by phenothiazine and neuroleptics, accidental (unintentional), initial T43.3X1A encounter Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, initial T43.3X2A encounter T43.3X3A Poisoning by phenothiazine antipsychotics and neuroleptics, assault, initial encounter

T43.3X4A Poisoning by phenothiazine antipsychotics and neuroleptics, undetermined, initial encounter Poisoning by butyrophenone and thiothixene neuroleptics, accidental (unintentional), initial T43.4X1A encounter Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial T43.4X2A encounter T43.4X3A Poisoning by butyrophenone and thiothixene neuroleptics, assault, initial encounter T43.4X4A Poisoning by butyrophenone and thiothixene neuroleptics, undetermined, initial encounter Poisoning by unspecified antipsychotics and neuroleptics, accidental (unintentional), initial T43.501A encounter Poisoning by unspecified antipsychotics and neuroleptics, intentional self-harm, initial T43.502A encounter T43.503A Poisoning by unspecified antipsychotics and neuroleptics, assault, initial encounter

T43.504A Poisoning by unspecified antipsychotics and neuroleptics, undetermined, initial encounter Poisoning by other antipsychotics and neuroleptics, accidental (unintentional), initial T43.591A encounter T43.592A Poisoning by other antipsychotics and neuroleptics, intentional self-harm, initial encounter T43.593A Poisoning by other antipsychotics and neuroleptics, assault, initial encounter T43.594A Poisoning by other antipsychotics and neuroleptics, undetermined, initial encounter

T43.601A Poisoning by unspecified psychostimulants, accidental (unintentional), initial encounter

T43.602A Poisoning by unspecified psychostimulants, intentional self-harm, initial encounter T43.603A Poisoning by unspecified psychostimulants, assault, initial encounter T43.604A Poisoning by unspecified psychostimulants, undetermined, initial encounter

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 11 of 13 ICD-10 CODE DESCRIPTION T43.611A Poisoning by caffeine, accidental (unintentional), initial encounter T43.612A Poisoning by caffeine, intentional self-harm, initial encounter T43.613A Poisoning by caffeine, assault, initial encounter T43.614A Poisoning by caffeine, undetermined, initial encounter T43.621A Poisoning by amphetamines, accidental (unintentional), initial encounter T43.622A Poisoning by amphetamines, intentional self-harm, initial encounter T43.623A Poisoning by amphetamines, assault, initial encounter T43.624A Poisoning by amphetamines, undetermined, initial encounter T43.631A Poisoning by methylphenidate, accidental (unintentional), initial encounter T43.632A Poisoning by methylphenidate, intentional self-harm, initial encounter T43.633A Poisoning by methylphenidate, assault, initial encounter T43.634A Poisoning by methylphenidate, undetermined, initial encounter T43.641A Poisoning by ecstasy, accidental (unintentional), initial encounter T43.641D Poisoning by ecstasy, accidental (unintentional), subsequent encounter T43.641S Poisoning by ecstasy, accidental (unintentional), sequela T43.642A Poisoning by ecstasy, intentional self-harm, initial encounter T43.642D Poisoning by ecstasy, intentional self-harm, subsequent encounter T43.642S Poisoning by ecstasy, intentional self-harm, sequela T43.643A Poisoning by ecstasy, assault, initial encounter T43.643D Poisoning by ecstasy, assault, subsequent encounter T43.643S Poisoning by ecstasy, assault, sequela T43.644A Poisoning by ecstasy, undetermined, initial encounter T43.644D Poisoning by ecstasy, undetermined, subsequent encounter T43.644S Poisoning by ecstasy, undetermined, sequela T43.691A Poisoning by other psychostimulants, accidental (unintentional), initial encounter T43.692A Poisoning by other psychostimulants, intentional self-harm, initial encounter T43.693A Poisoning by other psychostimulants, assault, initial encounter T43.694A Poisoning by other psychostimulants, undetermined, initial encounter T43.8X1A Poisoning by other psychotropic drugs, accidental (unintentional), initial encounter T43.8X2A Poisoning by other psychotropic drugs, intentional self-harm, initial encounter T43.8X3A Poisoning by other psychotropic drugs, assault, initial encounter T43.8X4A Poisoning by other psychotropic drugs, undetermined, initial encounter T43.91XA Poisoning by unspecified psychotropic drug, accidental (unintentional), initial encounter

T43.92XA Poisoning by unspecified psychotropic drug, intentional self-harm, initial encounter T43.93XA Poisoning by unspecified psychotropic drug, assault, initial encounter T43.94XA Poisoning by unspecified psychotropic drug, undetermined, initial encounter T45.0X1A Poisoning by antiallergic and drugs, accidental (unintentional), initial encounter

T45.0X2A Poisoning by antiallergic and antiemetic drugs, intentional self-harm, initial encounter T45.0X3A Poisoning by antiallergic and antiemetic drugs, assault, initial encounter T45.0X4A Poisoning by antiallergic and antiemetic drugs, undetermined, initial encounter Poisoning by cardiac-stimulant glycosides and drugs of similar action, accidental T46.0X1A (unintentional), initial encounter Poisoning by cardiac-stimulant glycosides and drugs of similar action, intentional self-harm, T46.0X2A initial encounter Poisoning by cardiac-stimulant glycosides and drugs of similar action, assault, initial T46.0X3A encounter Poisoning by cardiac-stimulant glycosides and drugs of similar action, undetermined, initial T46.0X4A encounter

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 12 of 13 ICD-10 CODE DESCRIPTION Poisoning by unspecified drugs, medicaments and biological substances, accidental T50.901A (unintentional), initial encounter Poisoning by unspecified drugs, medicaments and biological substances, intentional self- T50.902A harm, initial encounter Poisoning by unspecified drugs, medicaments and biological substances, assault, initial T50.903A encounter Poisoning by unspecified drugs, medicaments and biological substances, undetermined, T50.904A initial encounter Z03.821 Encounter for observation for suspected ingested foreign body ruled out Z03.822 Encounter for observation for suspected aspirated (inhaled) foreign body ruled out Z03.823 Encounter for observation for suspected inserted (injected) foreign body ruled out Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Z51.81 Encounter for therapeutic drug level monitoring Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate Z79.899 Other long term (current) drug therapy Z91.19 Patient's noncompliance with other medical treatment and regimen

Source: www.cms.hhs.gov/mcd DRUGS OF ABUSE TESTING Effective Date: 06-28-2016, last updated 10-1-2020 13 of 13